Medical Mgmt Clinical Coord-CMO

Montefiore Health System•Norfolk, VA

About The Position

Working with IPA providers, other members of the interdisciplinary care team, and CMO Medical Directors and in accordance with regulatory and benefit coverage parameters, helps determine and coordinate comprehensive care plans 'appropriate to the health care needs of IPA members, including but not limited to, inpatient hospitalization, outpatient services, professional services, home care, durable medical equipment and other ancillary services. Evening and weekend hours may be required.

Requirements

BSN or related field and 5 years clinical experience; or n combination of education and experience acceptable to the Director of Medical Management is required
Minimum 2 yrs. of recent experience in utilization management in a Managed Care Organization or case management in a Managed Care Organization required.
Certified in Utilization Review or Case Management preferred.
Experience in the use of Windows based software applications and data entry functions required.
Experience in interpreting and applying benefit coverage rules, and assessing coordination of benefits guidelines and managed care regulations required.
Excellent interpersonal/communication skills required (High proficiency)
Commitment to interdisciplinary teamwork required. (High proficiency)
New York State License for a Registered Professional Nurse and current registration A. New York State License for a Registered Professional Nurse and current registration Required
OHS Annual Assessment Required

Nice To Haves

Preferred 1-3 years

Responsibilities

Reviews and evaluates authorization requests for inpatient, outpatient, specialty and out-of-network care and all other services requiring authorization within time frames and in accordance with criteria/guidelines specified by departmental policies and procedures.
Completes 100% of assigned authorization reviews within the time frames required by regulation and specified by departmental policy and procedure or appropriately documents variances in any case not meeting timeframes.
Applies appropriate criteria/guidelines in the review of authorization requests.
Interprets criteria/guidelines accurately.
Acts as a resource to UM Analysts ia adjudicating authorizations as per departmental policy and procedure.
Identifies cages requiring case management and refers them to case management staff in accordance with depart mental guidelines.
Refers 100% of cases falling into those categories designated by departmental policy to appropriate case manager for evaluation.
Using guidelines/criteria specified in departmental policies and procedures, identifies cases where services requested may not be medically necessary, requests pertinent clinical information and forwards available information to the Medical Director or Associate Medical Director for review.
Reviews 100% of requests for service as well as ongoing care in accordance with appropriate criteria.
Documents efforts to obtain additional clinical information in accordance with departmental policy And procedure in 100% of cases where this is required.
Forwards identified cases involving issues of medical necessity to the Medical Director or Associate Medical Director for review.
Monitors Response time frames and or escalates to management all variances Facilitates the discharge planning process for hospitalized members.
Documents anticipated discharge plan at the time of the initial inpatient review.
Evaluates post discharge needs involving interdisciplinary professionals through daily rounds, team conferences and written communication.
Provides information as re: benefit coverage as needed, as well as available community services when appropriate.
Ensures that the discharge plan is communicated to all disciplines in a expeditious manner and identifies and documents barriers to a timely discharge.
Documents all variances resulting in potentially avoidable days in the UM system.
Provides timely documentation of discharge plan in 100% of cases to promote communication of plan between nurses performing case management and concurrent review functions Performs ongoing concurrent review of all assigned inpatient hospital admissions both in and out of network to determine appropriateness of admission and continued hospitalization.
When appropriate discusses member's hospitalization with attending and as needed reaches out to the Primary Care Physician (PCP) to determine PCP's previous level of involvement, as well as any social or medical issues that need to be considered in the formulation of a discharge plan that will meet expected outcomes of members hospitalization.
Conducts reviews in all cases where members are receiving extended services on a regular basis but at intervals of no greater than two weeks.
Conducts ongoing review at regular intervals that do not exceed three days in all cases.
Documents attempts to contact the Primary Care Physician,
Informs manager of all cases where length of stay extends beyond five days, and all cases where there is any obstacle to obtaining information necessary to determine the appropriateness of continued stay or to discharge at the point of medical stability, Monitors severity of illness and intensity of services based on accepted criteria.
If criteria are not met, refers to Associate Medical Director in accordance with Policy and Procedure for concurrent review.
Identifies and resolves and/or escalates systems problems that impact on the plan of care and document same
Collaborates with physicians and interdisciplinary team to ensure plan of care is congruent with accepted Length of Stay guidelines and documents all variances resulting in potentially avoidable days.
Proactively identifies potential and actual changes in the level of care required; communicates same to MD and interdisciplinary team members.
Documents notification of Manager of all inpatient stays exceeding five days and all cases where requests for concurrent review have not been fulfilled after 3 attempts within 2 working days.
Perform ongoing review in assigned cases where members are receiving extended services to ensure that members are receiving the services authorized and to determine the continued appropriateness of the services.
Conducts reviews in all cases where members are receiving extended services on a regular basis but at intervals of no greater than two weeks.
Documents involvement of the member and/or significant other(s), Primary Care Physician and/or specialist and all other involved health care providers are included in determining the need for ongoing care.
Modifies the plan of ongoing care as necessary in consultation with the member, significant other, Primary Care Physician and/or specialist and other involved health care providers.
Reviews cases with CMO Medical Director or Associate Medical Director, in accordance with departmental policies and procedures.
Identifies and accurately interprets clinical data elements required to appropriately apply criteria/guidelines in the review process and in the formulation of appropriate member-specific care.
Documentation consistently reflects a review of clinical data elements specific to R member's diagnosis and care plan.
Audit demonstrates consistency in documentation of appropriate criteria application.
Reviews all reminders, determines required follow-up and timeframe for follow-up within one working day of receipt.
Reviews 100% of urgent, high reminders received within one working day of receipt and medium within 3 days.
Documents review and plan for follow up 100% of the time.
Notifies manager 100% of the time if workload precludes review of urgent reminders within 1 working day.
Redirects care into the health plan network when appropriate.
Documents efforts to redirect out of plan referrals into the network.
Documents rationale for authorization of out of health plan network services.
Case documentation in the automated Utilization Management system is consistent with departmental policy.
Consistent score of 95% or above on departmental audits and timeliness.
Documents all authorizations completed in assigned cases by close of business on the day authorization is completed.
Documents contacts with members, providers and health plans in the appropriate screens within the automated Utilization Management system for assigned cases within one working day for urgent and emergent communication and in no less than 3 working days for non urgent and routine communication.
Documentation is consistent with all MM P&P's.
Identifies and documents cases requiring disease management.
Supplements ongoing patient education using materials provided by the CMO/Health Plan.
Uses CMO/Health Plan disease management guidelines 100% of the time, in a timely and effective manner, ensuring continuity of care.
Using CMO/Health Plan Guidelines, assesses and documents patient educational needs and reports 100% appropriate candidates for disease management to health plan.
Assists in the orientation of new staff.
Provides manager with feedback and updates on educational goals resolution for new staff.
Provides manager with suggestions concerning needs that previously had not been identified.
Act as a preceptor when deemed appropriate by manager.
Identifies and reports quality indicators involving members managed by the CMO to appropriate parties, such as the member's health plan, the MMC QI dept, the MMC risk management department and the CMO Medical Management Department.
Ensures that quality indicators are identified 100% of the time in accordance with Medical Management Policy and Procedure for Identifying and Reporting Quality Indicators.
Reports identified indicators to the appropriate internal and external personnel 100% of the time.
Documents with 100% compliance in automated UM system in accordance with Medical Management Policy and Procedure for Identifying and Reporting Quality.